Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
Chronic Disease and Injury Section, Division of Public Health, North Carolina Department of Health and Human Services, Injury and Violence Prevention Branch, Raleigh, North Carolina, USA.
Inj Prev. 2018 Feb;24(1):48-54. doi: 10.1136/injuryprev-2017-042396. Epub 2017 Aug 23.
In response to increasing opioid overdoses, US prevention efforts have focused on prescriber education and supply, demand and harm reduction strategies. Limited evidence informs which interventions are effective. We evaluated Project Lazarus, a centralised statewide intervention designed to prevent opioid overdose.
Observational intervention study of seven strategies. 74 of 100 North Carolina counties implemented the intervention. Dichotomous variables were constructed for each strategy by county-month. Exposure data were: process logs, surveys, addiction treatment interviews, prescription drug monitoring data. Outcomes were: unintentional and undetermined opioid overdose deaths, overdose-related emergency department (ED) visits. Interrupted time-series Poisson regression was used to estimate rates during preintervention (2009-2012) and intervention periods (2013-2014). Adjusted IRR controlled for prescriptions, county health status and time trends. Time-lagged regression models considered delayed impact (0-6 months).
In adjusted immediate-impact models, provider education was associated with lower overdose mortality (IRR 0.91; 95% CI 0.81 to 1.02) but little change in overdose-related ED visits. Policies to limit ED opioid dispensing were associated with lower mortality (IRR 0.97; 95% CI 0.87 to 1.07), but higher ED visits (IRR 1.06; 95% CI 1.01 to 1.12). Expansions of medication-assisted treatment (MAT) were associated with increased mortality (IRR 1.22; 95% CI 1.08 to 1.37) but lower ED visits in time-lagged models.
Provider education related to pain management and addiction treatment, and ED policies limiting opioid dispensing showed modest immediate reductions in mortality. MAT expansions showed beneficial effects in reducing ED-related overdose visits in time-lagged models, despite an unexpected adverse association with mortality.
为应对阿片类药物过量的增加，美国的预防工作重点是对处方医生进行教育，以及供应、需求和减少伤害策略。有限的证据表明哪些干预措施是有效的。我们评估了 Lazarus 项目，这是一项集中全州范围的干预措施，旨在预防阿片类药物过量。
对七种策略进行观察性干预研究。北卡罗来纳州的 100 个县中有 74 个实施了该干预措施。通过县-月构建了每个策略的二分变量。暴露数据包括：过程日志、调查、成瘾治疗访谈、处方药物监测数据。结果包括：意外和未确定的阿片类药物过量死亡、与过量相关的急诊部（ED）就诊。使用中断时间序列泊松回归估计干预前（2009-2012 年）和干预期间（2013-2014 年）的发生率。调整后的 IRR 控制了处方、县健康状况和时间趋势。时滞回归模型考虑了延迟影响（0-6 个月）。
在调整后的即时影响模型中，提供者教育与较低的过量死亡率相关（IRR 0.91；95%CI 0.81 至 1.02），但与过量相关的 ED 就诊量变化不大。限制 ED 阿片类药物配给的政策与较低的死亡率相关（IRR 0.97；95%CI 0.87 至 1.07），但 ED 就诊量较高（IRR 1.06；95%CI 1.01 至 1.12）。扩大药物辅助治疗（MAT）与死亡率增加相关（IRR 1.22；95%CI 1.08 至 1.37），但在时滞模型中，ED 相关的过量就诊量减少。
与疼痛管理和成瘾治疗相关的提供者教育，以及限制 ED 阿片类药物配给的政策显示出死亡率适度的即时降低。尽管与死亡率意外呈负相关，但 MAT 扩大在时滞模型中显示出降低与 ED 相关的过量就诊量的有益效果。
